Barriers and Pathways to Providing Long‐Acting Reversible Contraceptives in Massachusetts Community Health Centers: A Qualitative Exploration

Elizabeth Janiak,Harvard Medical SchoolJill Clark,Massachusetts Department of Public HealthDeborah Bartz,Harvard Medical SchoolAna Langer,Harvard T.H. Chan School of Public HealthBarbara Gottlieb,Harvard Medical School and Harvard T.H. Chan School of Public Health

CONTEXT

Structural barriers to the provision of long‐acting reversible contraceptive (LARC) methods at community health centers have been identified in quantitative research, but the processes and behaviors by which center staff respond to these barriers are poorly understood.

METHODS

Focus group discussions were conducted with clinical, support and administrative staff at three Massachusetts community health centers between April 2014 and January 2015. The centers were purposively selected to constitute a sample with diverse characteristics. Overall, 57 individuals participated in seven focus groups. Data were analyzed inductively using a modified grounded theory approach, and typical pathways to obtaining LARC methods were identified.

RESULTS

Community health center staff provided contradictory descriptions of their facilities’ protocols and practices. Patients’ pathways to obtaining LARC methods were idiosyncratic and clinician‐dependent, and resulted in patients’ waiting between one week and three months to receive their preferred method. Providers’ individual comfort with and perceived competence in contraceptive counseling often shaped patients’ pathways to care. Overall, staff did not consider same‐day insertion of LARC methods a feasible goal. Counseling protocols, insurance verification practices and logistical challenges in ordering and stocking devices were identified as major barriers to timely placement.

CONCLUSIONS

Efforts to improve LARC provision at community health centers should include the education of staff in how expeditious placement constitutes clinical best practice and the implementation of infrastructural changes to support staff in efficiently counseling patients, scheduling placements and procuring LARC devices regardless of patients’ insurance coverage.

Authors' Affiliations

Elizabeth Janiak is instructor, and Deborah Bartz is assistant professor, both in the Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston. Jill Clark is director, Office of Sexual Health and Youth Development, Massachusetts Department of Public Health, Boston. Ana Langer is professor, Women and Health Initiative, Harvard T.H. Chan School of Public Health, Harvard University, Boston. Barbara Gottlieb is associate professor, Department of Medicine, Harvard Medical School, and Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health.

Disclaimer
The views expressed in this publication do not necessarily reflect those of the Guttmacher Institute.

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